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How important is prediabetes to older people?

A few years ago, routine laboratory tests showed that Susan Glickman Weinberg, then a 65-year-old clinical social worker in Los Angeles, had a hemoglobin A1C level of 5.8%, just above the normal.

“This is considered prediabetes,” her internist told her. A1C measures the amount of sugar circulating in the bloodstream over time. Should his results reach 6% – still below the diabetes-defining number of 6.5 – his doctor said he would recommend the widely prescribed drug, metformin.

“The thought that I might have diabetes was very upsetting,” recalls Ms. Weinberg, who as a child had heard relatives talk about “this terrible and mysterious thing.”

She was already taking two blood pressure medications, a statin for cholesterol and an osteoporosis medication. Did she really need another prescription? She was also concerned about reports at the time of importation of contaminated drugs. She didn’t even know what prediabetes meant, or how quickly it could develop into diabetes.

“I felt like Patient Zero,” she says. “There were a lot of unknowns.”

Now there are fewer unknowns. A longitudinal study of older adults, published online this month in the journal JAMA Internal Medicine, provides answers on the very common intermediate condition known as prediabetes.

The researchers found that over several years, older people with suspected prediabetes were much more likely to have their blood sugar levels return to normal than to progress to diabetes. And they were no more likely to die during the follow-up period than their peers with normal blood sugar.

“In most older people, prediabetes probably shouldn’t be a priority,” said Elizabeth Selvin, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health in Baltimore and lead author of the study.

Prediabetes, a disease rarely discussed 15 years ago, refers to blood sugar levels that are above normal but have not crossed the threshold for diabetes. It is generally defined as a hemoglobin A1C reading of 5.7 to 6.4 percent or a fasting glucose level of 100 to 125 mg / dL; in quarantine, this can portend serious health problems.

A diagnosis of prediabetes means you’re more likely to develop diabetes, and “it leads to downstream disease,” said Dr. Kenneth Lam, geriatrician at the University of California at San Francisco and author of an accompanying editorial. the study. “It damages your kidneys, your eyes and your nerves. It causes a heart attack and a stroke, ”he said.

But for an older person with higher blood sugar levels, that’s another story. These terrible consequences take years to develop and many people between the ages of 70 and 80 will not live long enough to encounter them.

This fact has generated years of debate. Older people with slightly above normal blood sugar levels – a common occurrence because the pancreas produces less insulin later – should they act, as recommended by the American Diabetes Association?

Or does calling people prediabetes simply “medicalize” a normal part of aging, creating unnecessary anxiety for those who already face multiple health issues?

Dr. Selvin and her colleagues analyzed the results of an ongoing national cardiovascular risk study that began in the 1980s. When 3,412 of the participants presented for their physical exams and lab tests between 2011 and 2013, they had reached the age of 71 to 90 and did not have diabetes.

Prediabetes, however, was rampant. Almost three quarters are classified as prediabetic, based on their A1C or their fasting blood sugar.

These results reflected a 2016 study that pointed out that a popular online risk test created by the Centers for Disease Control and Prevention and the American Diabetes Association, called, would consider almost anyone over 60 to be prediabetic. .

In 2010, a CDC review reported that 9 to 25 percent of people with an A1C of 5.5 to 6 percent will develop diabetes over five years; The same will be true of 25 to 50 percent of those with A1C readings of 6 to 6.5. But these estimates were based on a middle-aged population.

When Dr. Selvin and his team looked at what really happened to their older prediabetic cohort five to six years later, only 8 or 9 percent had developed diabetes, depending on which definition they used.

A much larger group – 13% of those with elevated A1C and 44% of those with prediabetic fasting blood sugar – actually saw their readings return to normal blood sugar levels. (A Swedish study found similar results.)

Sixteen to 19 percent had died, roughly the same proportion as people without prediabetes.

“We don’t see a lot of risk in these people,” Dr. Selvin said. “Seniors can have complex health problems. Those that affect quality of life should be the focus, not slightly elevated blood sugar. “

Dr Saeid Shahraz, a health researcher at Tufts Medical Center in Boston and lead author of the 2016 study, praised the new research. “The data is really solid,” he said. “The American Diabetes Association should do something about this.”

It is possible, said Dr Robert Gabbay, scientific and medical director of the ADA. The organization currently recommends “at least annual monitoring” for people with prediabetes, a reference to lifestyle modification programs that reduce health risks and possibly to metformin for people who are obese and under. 60 years old.

Now, the association’s professional practice committee will be reviewing the study, and “it could lead to adjustments in the way we think about things,” said Dr. Gabbay. Among older people considered prediabetic, “their risk may be lower than we thought,” he added.

Advocates of the focus on treating prediabetes, which is believed to affect a third of the American population, point out that first-line treatment is learning healthy behaviors that more Americans should adopt anyway: weight loss, smoking cessation, exercise and healthy eating. .

“I have had a number of patients diagnosed with prediabetes, and this is what motivates them to change,” said Dr. Gabbay. “They know what they should be doing, but they need something to get them going.”

Geriatricians tend to disagree. “It is unprofessional to mislead people, to motivate them out of fear of something that is not really true,” Dr Lam said. “We are all tired of having things to fear.”

He and Dr Sei Lee, co-author of the editorial accompanying the new study and a geriatric colleague at the University of California, San Francisco, advocate for a case-by-case approach in the elderly – especially if diagnosed prediabetes will cause their children to berate them over every cookie.

For a fragile and vulnerable patient, “you probably face a whole host of other issues,” said Dr Lam. “Don’t worry about that number.”

A very healthy 75-year-old who could live another 20 years faces a more nuanced decision. It may never progress to diabetes; she can also already follow recommended lifestyle modifications.

Ms Weinberg, now 69, sought help from a nutritionist, changed her diet to focus on complex carbohydrates and protein, and started walking more and climbing stairs instead. to take elevators. She lost 10 pounds that she didn’t need to lose. In 18 months, her barely elevated A1C reading had dropped to 5.6.

Her friend Carol Jacobi, 71, who also lives in Los Angeles, received a similar warning around the same time. Her A1C was 5.7, the lowest number defined as prediabetic, but her internist immediately prescribed metformin.

Ms Jacobi, a retired fundraiser with no family history of diabetes, didn’t care. She thought she could lose some weight, but she had normal blood pressure and an active lifestyle that included a lot of walking and yoga. After trying the drug for a few months, she quit.

Now, no woman has prediabetes. Although Ms Jacobi did nothing to lower her blood sugar and put on a few pounds during the pandemic, her A1C also fell to normal levels.

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